Int. J. Environ. Res. Public Health 2014, 11, 12088-12107; doi:10.3390/ijerph111212088 OPEN ACCESS
International Journal of Environmental Research and Public Health ISSN 1660-4601 www.mdpi.com/journal/ijerph Article
Symptoms and Health Complaints and Their Association with Perceived Stressors among Students at Nine Libyan Universities Walid El Ansari 1,*, Khalid Khalil 2 and Christiane Stock 3 1 2 3
Faculty of Applied Sciences, University of Gloucestershire, Gloucester GL2 9HW, UK Faculty of Medical Technology, Misrata, Libya; E-Mail: [email protected] Unit for Health Promotion Research, Institute of Public Health, University of Southern Denmark, Esbjerg 6700, Denmark; E-Mail: [email protected]
* Author to whom correspondence should be addressed; E-Mail: [email protected]; Tel.: +44-1242-715-274; Fax: +44-1242-715-222. External Editor: Paul B. Tchounwou Received: 17 October 2014; in revised form: 12 November 2014 / Accepted: 12 November 2014 / Published: 25 November 2014
Abstract: University students are exposed to many stressors. We assessed the associations between two stressors (educational related and general overall), socio-demographic characteristics (five variables), health behaviours/lifestyle factors (six variables), as well as religiosity and quality of life as independent variables, with self-reported symptoms/health complaints as dependent variables (eight health complaints). A sample of 2100 undergraduate students from nine institutions (six universities, three colleges) located in seven cities in Libya completed a general health questionnaire. The most prevalent symptoms were headaches, depressive mood, difficulties to concentrate and sleep disorder/insomnia that have been reported by 50%–60% of the students. The majority of students (62%) reported having had three or more symptoms sometimes or very often in the last 12 months. There was a positive association between perceived stressors and health symptoms, which remained significant after adjustment for gender and many other relevant factors for headache (OR 1.52; 95% CI 1.15–2.02), depressive mood (OR 2.20; 95% CI 1.64–2.94) and sleep disorder/ insomnia (OR 1.55, 95% CI 1.19–2.03). Other factors independently associated with most health symptoms were female gender and poor self-perceived health. Stress management programmes and a reduction of educational
Int. J. Environ. Res. Public Health 2014, 11
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related stressors might help to prevent stress-related symptoms and health complaints in this student population. Keywords: self-reported symptoms/ health complaints; stressors; burdens; quality of life; university students
1. Introduction There is an increased focus on the health and well-being of students at higher education institutions, and calls that is “time for urgent action” for the health of these young adults [1]. In particular, educators are concerned about the sources of stress (stressors or burdens) amongst university students [2,3]. Stressors are “demands made by the internal or external environmental stimuli that affect the balance, thus influencing physical and psychological well-being of an individual and requiring actions to restore the balance” [4]. Whilst it is argued that stressors might beneficially motivate students’ achievement, performance, enhanced productivity and reward [5], their negative effects include self-reported symptoms, health complaints, psycho-somatic symptoms, or health strains. Such symptoms and complaints might be categorized into four groups: physical features (back pains, neck/ shoulder pains, headaches); gastrointestinal symptoms (stomach trouble/heartburn); psychological, psychiatric and mental health issues (depression, sleep disturbances, difficulties to concentrate); and circulatory complaints (rapid heartbeats, circulatory problems, dizziness) as manifestations of or associated with a range of stressors [2,6]. Students might be overwhelmed by their university experience to an extent that their physical and mental health could be negatively affected [7]. For example, perceived stressors related to studying were positively associated with higher depression among students from Germany, Poland and Bulgaria, by mediation via perceived stress and also directly [8]. The sources of such burdens/stressors for college students are many. One important aspect is the education or curricular (university study-related) stressors. Academic demands are considerable stressors [9], and the university period could be a stressor for students trying to achieve academic success despite financial constraints [10]. College students’ major stressors due to examinations suggested the use of reported symptoms for early detection of stress and proper intervention [11]. Stressors include personal expectations, peer competition, having to attain good grades, or fear of failing/repeating their course [12]. In Colombia, “fear of failing a course or year” was the highest ranked item, seen as very stressful by >60% of the sample, while “examinations and grades” ranked the third highest [13]. Other stressors/burdens are related to the general social atmosphere/environment of the students; e.g., being away from home, new socializations [12], and financial pressures [14]. Unsurprisingly, university students in many countries report educational-related and general stressors e.g., in Canada, UK, Egypt, Japan, Iran, and Jordan [2,6,15–18]. Similarly, university students across the globe report many symptoms/health complaints: in Japan, >40% of students had headache, stomach ache/abdominal pain, and stiff shoulder/backache within the past month [16]; and in the UK and Egypt, health complaints that occurred most often in the last year were fatigue, headache, difficulties to concentrate, back pain, neck/shoulder pain, and sleep disorders [2,6].
Int. J. Environ. Res. Public Health 2014, 11
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The stressors that students face and the accompanying health symptoms are an increasing problem that adversely affect their health. We investigated two types of stressors: college-related stressors; and general life stressors [19]. Better understanding of students’ symptoms (health complaints) and (educational or general) stressors and their frequencies, along with the associations between health complaints and students’ demographics and health behaviours, and the associations between individual symptoms and stressors are important to tailor effective interventions. Few studies of stressors and associated symptoms of university students have been conducted in some Eastern Mediterranean countries, and no such research has been implemented in Libya. Given this scarcity, together with challenges/ barriers imposed by the previous political regime in terms of accessing universities within Libya, such young adult college populations are hard-to-reach. The current research bridges these knowledge gaps, attaching high significance to the study’ contributions and findings. Aim of the Study This cross-sectional survey of a representative sample of undergraduate students across nine Libyan universities/ colleges (2008–2009) assessed the frequencies of self-reported students’ symptoms (eight health complaints) and two stressors (educational related and general overall). We also examined the associations between the health complaints and students’ socio-demographics (five variables—age, marital status, year of study, living arrangement during semester, income sufficiency) and health behaviours/lifestyle features (six variables—smoking, illicit drug/s, alcohol, subjective health, health awareness, BMI), as well as religiosity and quality of life. The study also explored the associations between the four most prevalent symptoms and stressors. The four specific objectives were to:
Describe the sample’s general characteristics; Assess the prevalence of eight symptoms, and the number of symptoms reported in the last 12 months; Assess the association between the frequency of the four most prevalent symptoms and students’ demographic characteristics and health behaviours; and Explore the frequency of symptoms by extent of perceived stressors (burdens); and the association between the four most prevalent symptoms and perceived stressors while controlling for all other symptom groups.
2. Materials and Methods 2.1. Sample, Data Collection and Ethics The study was approved by research/ethics committees at the participating institutions. A representative sample of students was sought at the universities by selecting courses that represented the different departments/faculties. Questionnaires (self-administered) were distributed to students attending the selected sessions, and collected after completion. Participation was voluntary and anonymous, and data were confidential and protected. All data were computer-entered by the second author for quality assurance. The questionnaire was provided to 2100 students, and 1567 completed questionnaires were returned (response rate ≈ 74.6%), of which 267 questionnaires were excluded (missing data), leaving 1300 questionnaires for analysis (439 males, 33.8%; 861 females, 66.2%; M age 20.9 years,
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SD 2.4). Nine institutions (six universities, three colleges) in seven cities (Misurata, Sabha, Zawea, Sirt, Al Bida, Benghazi, Tripoli) participated, thus the sample was representative of Libyan higher education institutions and of many scientific/academic disciplines: e.g., Agriculture, Business, Education, Law, Mechanical Engineering, Medical Science, Medical Technology, and others. In Libya (academic year 2010/2011), more than 90% of the university students were enrolled in public universities (59% females). Thus the current study included most public universities in order to ensure representativeness of the study sample to the greater population of university students in Libya. In addition, geographically, the universities that were included in the study were situated across Libya, in the north, west, east and south, also ensuring representativeness of the study sample. Generally in Libya, Higher Education is completely financed by the state, except for private universities. All high school students have the access to higher education institutions. Every year, the Cabinet determines the regulations for students’ admission to higher education institutions by considering the results of the “Secondary School Leaving Certificate”, the needs of society, and institutions’ capacities. Students’ fees are very small; students pay only registration fees at the beginning of the academic year or semester. In terms of the economic situation, until recently Libya was classified as a high-income country, but has lately moved to low-income country status. 2.2. Health and Wellbeing Measures and Variables This general student health survey [2–4,6,20–27] utilized a questionnaire that included general health/wellbeing information, perceived stressors (burdens), and nine symptoms/health complaints. The data comprised gender, age, marital status, year of study, living arrangements (during semester), smoking, alcohol consumption, subjective health status, health awareness, height and weight (to compute BMI), importance of religion/personal faith (religiosity), and income sufficiency. Perceived Stressors (burdens) (two items): one item focused on students’ educational/university related burdens (course work, exams): “To what extent do you feel burdened in the following areas?”. The second item assessed general burdens overall. “Considering your current situation, to what extent do you feel burdened overall?” [8,28]. Health problems, symptoms/ health complaints (eight items): students rated eight symptoms/health complaints [2,3,29]. “How often have you had these complaints during the past 12 months?” (1 = “never”; 4 = “very often”), e.g., stomach trouble/heartburn, back pain, rapid heart beats/circulatory problem/dizziness, headaches, sleep disorder/ insomnia, concentration difficulties, neck and shoulder pain, and depressive mood. In our sample, Cronbach’s alpha (whole scale) was 0.74. Marital status: “What is your marital status?” (“Married”, and “Single”). Living arrangements during semester time: “Where do you live (during university/college term time)?” with two options based on whether the participant was living with parents or not. Tobacco smoking: “Within the last three months, how often did you smoke? (cigarettes, pipes, cigarillos, cigars)” (“daily”, “occasionally”, “never”) [30]. Illicit drug/s use: “Have you ever use/used drugs?” (“Yes, regularly”, “Yes, but only a few times”, “Never”), recoded into two options based on whether the participant ever used illicit drug/s or not [24]. Alcohol consumption frequency: “Over the past three months how often have you drunk alcohol, e.g., beer?” (six options: “never”, “once a week or less”, “once a week”, “a few times each week”, “every day”, and “a few times each day”).
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Subjective health status: “How would you rate your health in general?” (1 = “excellent”, 5 = “poor”) [31]. Health awareness: “To what extent do you keep an eye on your health?” (1 = “not at all”, 4 = “very much”) [28]. BMI (reported): calculated from self-reported weight and height using Metric BMI Formula (BMI (kg/m2) = weight in kilograms/squared height (m2)), and categorised into: underweight (BMI < 18.5 kg/m2), normal (18.5 ≤ BMI ≤ 24.9 kg/m2), overweight (25.0 ≤ BMI ≤ 29.9 kg/m2), or obese (BMI ≥ 30.0 kg/m2) [32]. Importance of religion/personal faith (religiosity: “My religion is very important for my life?” (1= “strongly disagree”, 5= “strongly agree”), recoded into two options based on whether the participant agreed or not. Income sufficiency (subjective economic situation): how sufficient students considered the amount of money they have at their disposal (4-point scale: “always sufficient”, “mostly sufficient”, “mostly insufficient”, “always insufficient”). Quality of one’s life: “If you consider the quality of your life: How did things go for you in the last four weeks?” (1 = “very badly”, 5 = “very well”) [33], later recoded into three categories. 2.3. Statistical Analysis The Statistical Package SPSS v19.0 was used for the statistical analyses (p set at
International Journal of Environmental Research and Public Health ISSN 1660-4601 www.mdpi.com/journal/ijerph Article
Symptoms and Health Complaints and Their Association with Perceived Stressors among Students at Nine Libyan Universities Walid El Ansari 1,*, Khalid Khalil 2 and Christiane Stock 3 1 2 3
Faculty of Applied Sciences, University of Gloucestershire, Gloucester GL2 9HW, UK Faculty of Medical Technology, Misrata, Libya; E-Mail: [email protected] Unit for Health Promotion Research, Institute of Public Health, University of Southern Denmark, Esbjerg 6700, Denmark; E-Mail: [email protected]
* Author to whom correspondence should be addressed; E-Mail: [email protected]; Tel.: +44-1242-715-274; Fax: +44-1242-715-222. External Editor: Paul B. Tchounwou Received: 17 October 2014; in revised form: 12 November 2014 / Accepted: 12 November 2014 / Published: 25 November 2014
Abstract: University students are exposed to many stressors. We assessed the associations between two stressors (educational related and general overall), socio-demographic characteristics (five variables), health behaviours/lifestyle factors (six variables), as well as religiosity and quality of life as independent variables, with self-reported symptoms/health complaints as dependent variables (eight health complaints). A sample of 2100 undergraduate students from nine institutions (six universities, three colleges) located in seven cities in Libya completed a general health questionnaire. The most prevalent symptoms were headaches, depressive mood, difficulties to concentrate and sleep disorder/insomnia that have been reported by 50%–60% of the students. The majority of students (62%) reported having had three or more symptoms sometimes or very often in the last 12 months. There was a positive association between perceived stressors and health symptoms, which remained significant after adjustment for gender and many other relevant factors for headache (OR 1.52; 95% CI 1.15–2.02), depressive mood (OR 2.20; 95% CI 1.64–2.94) and sleep disorder/ insomnia (OR 1.55, 95% CI 1.19–2.03). Other factors independently associated with most health symptoms were female gender and poor self-perceived health. Stress management programmes and a reduction of educational
Int. J. Environ. Res. Public Health 2014, 11
12089
related stressors might help to prevent stress-related symptoms and health complaints in this student population. Keywords: self-reported symptoms/ health complaints; stressors; burdens; quality of life; university students
1. Introduction There is an increased focus on the health and well-being of students at higher education institutions, and calls that is “time for urgent action” for the health of these young adults [1]. In particular, educators are concerned about the sources of stress (stressors or burdens) amongst university students [2,3]. Stressors are “demands made by the internal or external environmental stimuli that affect the balance, thus influencing physical and psychological well-being of an individual and requiring actions to restore the balance” [4]. Whilst it is argued that stressors might beneficially motivate students’ achievement, performance, enhanced productivity and reward [5], their negative effects include self-reported symptoms, health complaints, psycho-somatic symptoms, or health strains. Such symptoms and complaints might be categorized into four groups: physical features (back pains, neck/ shoulder pains, headaches); gastrointestinal symptoms (stomach trouble/heartburn); psychological, psychiatric and mental health issues (depression, sleep disturbances, difficulties to concentrate); and circulatory complaints (rapid heartbeats, circulatory problems, dizziness) as manifestations of or associated with a range of stressors [2,6]. Students might be overwhelmed by their university experience to an extent that their physical and mental health could be negatively affected [7]. For example, perceived stressors related to studying were positively associated with higher depression among students from Germany, Poland and Bulgaria, by mediation via perceived stress and also directly [8]. The sources of such burdens/stressors for college students are many. One important aspect is the education or curricular (university study-related) stressors. Academic demands are considerable stressors [9], and the university period could be a stressor for students trying to achieve academic success despite financial constraints [10]. College students’ major stressors due to examinations suggested the use of reported symptoms for early detection of stress and proper intervention [11]. Stressors include personal expectations, peer competition, having to attain good grades, or fear of failing/repeating their course [12]. In Colombia, “fear of failing a course or year” was the highest ranked item, seen as very stressful by >60% of the sample, while “examinations and grades” ranked the third highest [13]. Other stressors/burdens are related to the general social atmosphere/environment of the students; e.g., being away from home, new socializations [12], and financial pressures [14]. Unsurprisingly, university students in many countries report educational-related and general stressors e.g., in Canada, UK, Egypt, Japan, Iran, and Jordan [2,6,15–18]. Similarly, university students across the globe report many symptoms/health complaints: in Japan, >40% of students had headache, stomach ache/abdominal pain, and stiff shoulder/backache within the past month [16]; and in the UK and Egypt, health complaints that occurred most often in the last year were fatigue, headache, difficulties to concentrate, back pain, neck/shoulder pain, and sleep disorders [2,6].
Int. J. Environ. Res. Public Health 2014, 11
12090
The stressors that students face and the accompanying health symptoms are an increasing problem that adversely affect their health. We investigated two types of stressors: college-related stressors; and general life stressors [19]. Better understanding of students’ symptoms (health complaints) and (educational or general) stressors and their frequencies, along with the associations between health complaints and students’ demographics and health behaviours, and the associations between individual symptoms and stressors are important to tailor effective interventions. Few studies of stressors and associated symptoms of university students have been conducted in some Eastern Mediterranean countries, and no such research has been implemented in Libya. Given this scarcity, together with challenges/ barriers imposed by the previous political regime in terms of accessing universities within Libya, such young adult college populations are hard-to-reach. The current research bridges these knowledge gaps, attaching high significance to the study’ contributions and findings. Aim of the Study This cross-sectional survey of a representative sample of undergraduate students across nine Libyan universities/ colleges (2008–2009) assessed the frequencies of self-reported students’ symptoms (eight health complaints) and two stressors (educational related and general overall). We also examined the associations between the health complaints and students’ socio-demographics (five variables—age, marital status, year of study, living arrangement during semester, income sufficiency) and health behaviours/lifestyle features (six variables—smoking, illicit drug/s, alcohol, subjective health, health awareness, BMI), as well as religiosity and quality of life. The study also explored the associations between the four most prevalent symptoms and stressors. The four specific objectives were to:
Describe the sample’s general characteristics; Assess the prevalence of eight symptoms, and the number of symptoms reported in the last 12 months; Assess the association between the frequency of the four most prevalent symptoms and students’ demographic characteristics and health behaviours; and Explore the frequency of symptoms by extent of perceived stressors (burdens); and the association between the four most prevalent symptoms and perceived stressors while controlling for all other symptom groups.
2. Materials and Methods 2.1. Sample, Data Collection and Ethics The study was approved by research/ethics committees at the participating institutions. A representative sample of students was sought at the universities by selecting courses that represented the different departments/faculties. Questionnaires (self-administered) were distributed to students attending the selected sessions, and collected after completion. Participation was voluntary and anonymous, and data were confidential and protected. All data were computer-entered by the second author for quality assurance. The questionnaire was provided to 2100 students, and 1567 completed questionnaires were returned (response rate ≈ 74.6%), of which 267 questionnaires were excluded (missing data), leaving 1300 questionnaires for analysis (439 males, 33.8%; 861 females, 66.2%; M age 20.9 years,
Int. J. Environ. Res. Public Health 2014, 11
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SD 2.4). Nine institutions (six universities, three colleges) in seven cities (Misurata, Sabha, Zawea, Sirt, Al Bida, Benghazi, Tripoli) participated, thus the sample was representative of Libyan higher education institutions and of many scientific/academic disciplines: e.g., Agriculture, Business, Education, Law, Mechanical Engineering, Medical Science, Medical Technology, and others. In Libya (academic year 2010/2011), more than 90% of the university students were enrolled in public universities (59% females). Thus the current study included most public universities in order to ensure representativeness of the study sample to the greater population of university students in Libya. In addition, geographically, the universities that were included in the study were situated across Libya, in the north, west, east and south, also ensuring representativeness of the study sample. Generally in Libya, Higher Education is completely financed by the state, except for private universities. All high school students have the access to higher education institutions. Every year, the Cabinet determines the regulations for students’ admission to higher education institutions by considering the results of the “Secondary School Leaving Certificate”, the needs of society, and institutions’ capacities. Students’ fees are very small; students pay only registration fees at the beginning of the academic year or semester. In terms of the economic situation, until recently Libya was classified as a high-income country, but has lately moved to low-income country status. 2.2. Health and Wellbeing Measures and Variables This general student health survey [2–4,6,20–27] utilized a questionnaire that included general health/wellbeing information, perceived stressors (burdens), and nine symptoms/health complaints. The data comprised gender, age, marital status, year of study, living arrangements (during semester), smoking, alcohol consumption, subjective health status, health awareness, height and weight (to compute BMI), importance of religion/personal faith (religiosity), and income sufficiency. Perceived Stressors (burdens) (two items): one item focused on students’ educational/university related burdens (course work, exams): “To what extent do you feel burdened in the following areas?”. The second item assessed general burdens overall. “Considering your current situation, to what extent do you feel burdened overall?” [8,28]. Health problems, symptoms/ health complaints (eight items): students rated eight symptoms/health complaints [2,3,29]. “How often have you had these complaints during the past 12 months?” (1 = “never”; 4 = “very often”), e.g., stomach trouble/heartburn, back pain, rapid heart beats/circulatory problem/dizziness, headaches, sleep disorder/ insomnia, concentration difficulties, neck and shoulder pain, and depressive mood. In our sample, Cronbach’s alpha (whole scale) was 0.74. Marital status: “What is your marital status?” (“Married”, and “Single”). Living arrangements during semester time: “Where do you live (during university/college term time)?” with two options based on whether the participant was living with parents or not. Tobacco smoking: “Within the last three months, how often did you smoke? (cigarettes, pipes, cigarillos, cigars)” (“daily”, “occasionally”, “never”) [30]. Illicit drug/s use: “Have you ever use/used drugs?” (“Yes, regularly”, “Yes, but only a few times”, “Never”), recoded into two options based on whether the participant ever used illicit drug/s or not [24]. Alcohol consumption frequency: “Over the past three months how often have you drunk alcohol, e.g., beer?” (six options: “never”, “once a week or less”, “once a week”, “a few times each week”, “every day”, and “a few times each day”).
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Subjective health status: “How would you rate your health in general?” (1 = “excellent”, 5 = “poor”) [31]. Health awareness: “To what extent do you keep an eye on your health?” (1 = “not at all”, 4 = “very much”) [28]. BMI (reported): calculated from self-reported weight and height using Metric BMI Formula (BMI (kg/m2) = weight in kilograms/squared height (m2)), and categorised into: underweight (BMI < 18.5 kg/m2), normal (18.5 ≤ BMI ≤ 24.9 kg/m2), overweight (25.0 ≤ BMI ≤ 29.9 kg/m2), or obese (BMI ≥ 30.0 kg/m2) [32]. Importance of religion/personal faith (religiosity: “My religion is very important for my life?” (1= “strongly disagree”, 5= “strongly agree”), recoded into two options based on whether the participant agreed or not. Income sufficiency (subjective economic situation): how sufficient students considered the amount of money they have at their disposal (4-point scale: “always sufficient”, “mostly sufficient”, “mostly insufficient”, “always insufficient”). Quality of one’s life: “If you consider the quality of your life: How did things go for you in the last four weeks?” (1 = “very badly”, 5 = “very well”) [33], later recoded into three categories. 2.3. Statistical Analysis The Statistical Package SPSS v19.0 was used for the statistical analyses (p set at
